Subungual hematoma greater than 50% of the nail requires which initial management step?

Subungual hematoma greater than 50% of the nail requires which initial management step?

• A. Do not treat; observe
• B. Obtain MRI
• C. Remove the nail and suture
• D. Trephination to relieve pressure

Answer: (D)

When a subungual hematoma covers more than half of the nail, pressure builds under the nail bed and can impair blood flow to the tissue. The best initial step is to relieve that pressure by trephination, which creates a small hole in the nail plate to drain the accumulated blood. This decompresses the nail bed, provides rapid pain relief, and helps prevent nail-bed ischemia without the need for more invasive procedures. It’s typically done in the clinic under local anesthesia with sterile technique, using a heated needle or a small drill to make the opening. Observing without treatment isn’t appropriate here because significant pressure poses a risk to the underlying tissues. MRI isn’t useful acutely and won’t relieve pressure. Removing the nail and suturing is more invasive and reserved for cases where trephination isn’t possible, there’s a nail bed tear, or persistent bleeding; it isn’t the first step for a large hematoma.

When a subungual hematoma covers more than half of the nail, pressure builds under the nail bed and can impair blood flow to the tissue. The best initial step is to relieve that pressure by trephination, which creates a small hole in the nail plate to drain the accumulated blood. This decompresses the nail bed, provides rapid pain relief, and helps prevent nail-bed ischemia without the need for more invasive procedures. It’s typically done in the clinic under local anesthesia with sterile technique, using a heated needle or a small drill to make the opening.

Observing without treatment isn’t appropriate here because significant pressure poses a risk to the underlying tissues. MRI isn’t useful acutely and won’t relieve pressure. Removing the nail and suturing is more invasive and reserved for cases where trephination isn’t possible, there’s a nail bed tear, or persistent bleeding; it isn’t the first step for a large hematoma.